The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?
The nurse waits 5 minutes between administering prescribed eye drops.
The nurse leaves the eye shield in place while the client sleeps.
The nurse is instructing the client not to drive at night.
The nurse encourages the client to exercise with 20 lb weights 1 day post-operatively.
The Correct Answer is D
Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.
Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.
Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.
Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Right upper quadrant pain is a common clinical manifestation of cholecystitis, which is inflammation of the gallbladder. The pain is often severe and can radiate to the back or shoulder. It is usually triggered by the intake of fatty foods and may be accompanied by other symptoms such as nausea and vomiting.
Choice B reason: Right lower leg pain is not associated with cholecystitis. This type of pain could indicate other conditions such as deep vein thrombosis or musculoskeletal issues.
Choice C reason: A positive Babinski sign indicates central nervous system dysfunction and is not related to cholecystitis. It involves dorsiflexion of the big toe and fanning of the other toes when the sole of the foot is stimulated.
Choice D reason: Yawning at mass is irrelevant to the diagnosis of cholecystitis. It could indicate tiredness or boredom but has no clinical significance related to gallbladder inflammation.
Correct Answer is B
Explanation
Choice A reason: Verifying the conductive gel pads is important but should be done before the command "CLEAR!" is given.
Choice B reason: Stepping away from the bed and ensuring others have done the same is crucial for safety. It prevents accidental electrical shock to anyone touching the patient or bed during defibrillation.
Choice C reason: Shutting off the intravenous infusion is not necessary during defibrillation. It does not pose a safety risk in this context.
Choice D reason: Shutting off the mechanical ventilator is not necessary during defibrillation and could compromise the patient's ventilation status.
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